Medical Image of the Week: Lymphangitic Carcinomatosis

Figure 1. Mass like consolidation and interlobular septal thickening (arrows). 

A 64-year-old woman, never-smoker, was evaluated for shortness of breath and left leg swelling. An abnormal initial chest X-Ray lead to computed tomography (CT) scan of the chest. She was also diagnosed with deep vein thrombosis (DVT) of her left leg.

CT of the chest with intravenous contrast showed a mass-like consolidation in the right upper lobe and thickening of the peripheral interlobular septa and of the bronchovascular bundles consistent with lymphangitic carcinomatosis (Figure 1). Endobronchial ultrasound (EBUS) guided transbronchial needle aspirations of the station 10 R Lymph node were positive for adenocarcinoma of lung origin.

Lymphangitic carcinomatosis occurs when cancer cells spread along the pulmonary lymphatic system and result in thickening of the bronchovascular bundle, the interlobular septa, or both (1). Histopathologically, specimens show interlobular and subpleural interstitial desmoplastic thickening and obstruction of lymphatic vessels by tumor cells. It carries a poor prognosis.

Mohammad R. Dalabih, MBBS¹ and Joshua Malo, MD²

¹Pulmonary Consultants LLC, Tacoma, WA USA

²Division of Pulmonary, Allergy, Critical Care. And Sleep, University of Arizona College of Medicine, Tucson, AZ USA

Reference

1. Munk PL, Müller NL, Miller RR, Ostrow DN. Pulmonary lymphangitic carcinomatosis: CT and pathologic findings. Radiology. 1988 Mar;166(3):705-9. [CrossRef] [PubMed]

Cite as: Dalabih MR, Malo J. Medical image of the week: lymphangitic cacinomatosis. Southwest J Pulm Crit Care. 2017;14(5):240. doi: https://doi.org/10.13175/swjpcc053-17 PDF

Medical Image of the Week: May-Thurner Syndrome

Figure 1. Figure A: Venogram showing extensive thrombosis of the left common iliac vein. Thrombus appearing as filling defects (arrows). Patient is in prone position. Figure B: Venogram after catheter-directed pharmaco-mechanical thrombectomy and stent placement (2). Inferior vena cava filter in place (1). Patient is in prone position. Figure C: Venogram after catheter-directed pharmaco-mechanical thrombectomy and stent (arrow) placement showing improved venous flow. Patient is in prone position.

A 20-year-old Caucasian female presented with 7-day history of pain and swelling of the left lower extremity. She had no significant past medical history. Her only medication at the time of presentation was oral contraceptive pills. She denied smoking cigarettes. She denied shortness of breath, recent travel, surgery or miscarriage. She did not have any family history of clotting problems. She was hemodynamically stable. Physical examination was significant for swelling of the left lower extremity up to mid-thigh level. Duplex ultrasonography of the extremity showed extensive thrombosis of the left ilio-femoral, common femoral and popliteal veins. A retrievable inferior vena cava filter was placed. Subsequently, she underwent catheter directed thrombolysis and percutaneous mechanical thrombectomy.  Venogram, after the procedure showed resolution of most of the clot burden. It also revealed a band-like stenosis at the location where the right iliac artery is expected to cross the left iliac vein, consistent with May-Thurner syndrome. Endovascular stenting was done. Following the placement of stent venous flow improved significantly. The inferior vena cava filter was removed about a week later. She completed 6 months of anticoagulation with warfarin. Screening for hypercoagulable state, including protein C and S level, antithrombin III level, homocysteine level, anti-phospholipid antibody, factor V Leiden mutation and prothrombin gene mutation was negative.

May-Thurner syndrome is an anatomical variation of the left common iliac vein that increases the risk of deep venous thrombosis of the left lower extremity. It is caused by the compression of the left iliac vein by the right iliac artery against the fifth lumbar vertebra, where it crosses over the vein. Chronic pulsation of the artery against the vein causes vascular thickening. Patients are usually females and commonly present in their second to fourth decades of life. The estimated prevalence is about 22% in the general population. So, it should be suspected when younger females present with extensive, proximal deep venous thrombosis of the left lower extremity. Patients are at increased risk of recurrent thrombosis which can be prevented by correction of the anatomical lesion.

Sathish Krishnan MD, Malav Parikh MD, Dima Dandachi MD

Department of Internal Medicine

Saint Francis Hospital

Evanston, IL

References

1. Kalu S, Shah P, Natarajan A, Nwankwo N, Mustafa U, Hussain N.. May-Thurner Syndrome: A Case Report and Review of the Literature. Case Rep Vasc Med. 2013; 2013:740182. [CrossRef] [PubMed]
2. Peters M, Syed RK, Katz M, Moscona J, Press C, Nijjar V, Bisharat M, Baldwin D. May-Thurner syndrome: a not so uncommon cause of a common condition. Proc (Bayl Univ Med Cent) ; 25(3):231-3. [PubMed]

Reference as: Krishnan S, Parikh M, Dandachi D. Medical image of the week: May-Thurner syndrome. Southwest J Pulm Crit Care. 2014;9(1):25-26. doi: http://dx.doi.org/10.13175/swjpcc066-14 PDF

Medical Image of the Week: Metastatic Melanoma with Hemorrhage

Figure 1. Axial image of CT Chest with contrast showing pulmonary metastatic masses and alveolar opacities consistent with pulmonary hemorrhage.

Figure 2. Coronal image of CT Chest with contrast showing innumerable pulmonary nodules and masses along with ground-glass alveolar opacities representing alveolar hemorrhage.

A 62 year-old gentleman presented with right leg swelling due to an extensive DVT in the right femoral vein.  He was found to have a right groin mass attributed to metastatic malignant melanoma.  Chest X-ray and CT revealed multiple bilateral pulmonary nodules.  He was started on warfarin 3mg daily for acute DVT and referred to Oncology.  2 weeks later he developed hemoptysis and was found to be hypoxemic.  He was admitted to our MICU.  His INR upon admission was 8.2 and hemoglobin 6.4.  CT Chest showed innumerable bilateral pulmonary nodules and ground-glass alveolar opacities with thickening and nodularity of intra-lobular septa adjacent to the nodules.  Warfarin was held and packed RBC and FFP transfusions were given with progressive improvement in hemoptysis and pulmonary status.

Tauseef Afaq Siddiqi, MD; Abdulmajid Eddib, MD; Phillip Factor, DO; and Steven Knoper, MD

Department of Medicine

Section of Pulmonary, Allergy, Critical Care and Sleep Medicine

The University of Arizona

Tucson, AZ 85724, USA

Reference as: Siddiqi TA, Eddib A, Factor P, Knoper S. Medical image of the week: metastatic melanoma with hemorrhage. Southwest J Pulm Crit Care. 2013;6(6):287-8. http://dx.doi.org/10.13175/swjpcc079-13 PDF